1. Pelvic Floor Anatomy and Female Lower Urinary Tract Dysfunction
Hann-Chorng Kuo
Department of Urology
Buddhist Tzu Chi General Hospital

2. Abdomino-pelvic cavity
Respiratory diaphragm
Vertebral column
Abdominal muscles
Pelvic floor
Intra-abdominal pressure
Visceral weight & Gravity in erect body
Maintain visceral function

3. Genital Support
Pelvic floor- Pelvic visceral attachment to pelvic walls through endopelvic fascia
Levator ani muscles- a pelvic diaphragm with a cleft in anterior portion
Urogenital diaphragm connects perineal body to ischiopubic rami
Bulocavernous, ischiocavernous, sup.transverse perineal, anal sphincter m.

4. Endopelvic fascia

5. Levator ani muscles
Pelvic diaphragm composed of levator ani, coccygeus, obturator internus, and piriformis muscles
Levator ani consists of medial pubococcygeus and lateral iliococcygeus muscles
Pelvic diaphragm composed of levator ani, coccygeus, obturator

6. The Pelvic Diaphragm

7. The Pelvic Floor Muscles

8. The Pelvic Floor Muscles

9. The puborectalis muscle (Inferior fibers of pubococcygeus)

10. The Puborectalis muscle

11. The Urogenital Diaphragm

12. Female Perineum

13. The Function of Pelvic Floor
Support pelvic and abdominal organs during stress of increased abdominal pressure
Allow for opening of the pelvic floor to accommodate excretory functions and parturition
Endopelvic fascia and visceral ligaments contains smooth muscles

14. The Pelvic Floor Attachments
Pelvic floor support depends on its connection to the pelvic bones
An evolutionary solution for support of visceral organs
Pelvic floor muscles oppose gravity and increased abdominal pressures

15. Prevention of Prolapse
Constriction – levator ani muscles constrict lumen of vagina
Suspension –cardinal ligaments & uterosacral ligaments, pubocervical fascia act to suspend cervix and vagina
Flap valve mechanism- anterior traction of levator ani m. and suspension of vagina in posterior pelvis

16. Prevention of Prolapse

17. Attachments of Pelvic Floor
Tendinous arch of pelvic fascia- pubocervical fascia arises
Tendinous arch of levator ani- levator ani muscles arise
Pubourethral ligaments
Pubovesical ligaments

18. Attachments of Pelvic Floor

19. Pelvic Floor Dysfunction
A variety of fascial and anatomic defects
Cystocele, rectocele, uterine prolapse, enterocele, vault prolapse
Adequate diagnosis and staging of pelvic floor dysfunction is essential

20. Diagnosis of Pelvic Floor Dysfunction
Detailed physical examination
Pelvic ultrasound
Fluoroscopy of rectum & bladder
Magnetic resonance imaging (MRI)

21. Image Study of Pelvic Floor

22. The Urethropelvic Ligaments
Bladder
Smooth muscle
Striated
Symphysis pubis
Striated muscle
Smooth muscle
Urethropelvic ligament
Smooth muscle

23. Descent of Bladder during Stress

24. Cystocele Most Gr 1 and 2 cystoceles are asymptomatic
High grade cystoceles are associated with vaginal buldging, vaginal pressure, dyspareunia, UTI, obstructive voiding, urinary retention
A high grade cystocele may mask urethral hypermobility and stress incontinence

25. Physical examination of Cystocele

26. MRI of Cystocele

27. Enterocele Simple enterocele
Complex enterocele- associated with vault prolapse and anterior or posterior vaginal prolapse
Cause vaginal pressure, dyspareunia, low back pain, constipation, symptoms of bowel obstruction

28. Physical examination of Vaginal Cuff Prolapse

29. MRI of Enterocele

30. Rectocele
Defect of prerectal and pararectal fascia,and rectovaginal septum
Present in 80% asymptomatic patients
Vaginal mass,vaginal pressure, dyspareunia,constipation

31. Physical examination of Rectocele

32. MRI of Rectocele

33. Uterine Prolapse Laxity of uterosacral ligaments
May present with vaginal mass, dyspareunia, urinary retention, back pain
Grade 4 prolapse is associated with ureteral obstruction

34. Physical examination of Uterine Prolapse

35. MRI of Uetrine Prolapse

36. Complete Eversion of Vaginal Vault

37. The Continence Mechanism

38. The Urethral Sphincter and Pelvic Floor

39. The External Urethral Sphincter

40. Pelvic Floor Relaxation
Associated with damage to pubococcygeus muscle
The muscle is lax, atrophied, poor tone
Urinary stress incontinence
Genital prolapse
Sexual Problem
Rectal stasis

41. Muscular Component of Pubococcygeus muscle
Large diameter slow twitch type I fibers predominant- provide static visceral support
Fast twitch type II fibers- assists in active closure of pelvic visceral organs
40% of women have lost function or coordination of this muscle

42. The Structures supporting Bladder and Urethra
Arcus tendineus fascia pelvis
Levator ani (pubococcygeus muscles)
Pubovesical muscles or ligaments
Vaginal muscle attachments to fascia and levator ani

43. The Structures supporting Bladder and Urethra

44. The Structures supporting Bladder and Urethra

45. The Hammock Theory of Extrinsic Continence Mechanism

46. Increased Abdominal Pressure against Supportive Fascia

47. The Integral Theory of Extrinsic Continence Theory

48. Pelvic Floor Relaxation and Abdominal Leak Point Pressure

49. Pelvic Floor Relaxation Low LPP without Hypermobility

50. Pelvic Floor Relaxation High LPP with hypermobility

51. Pelvic Floor Relaxation CLPP > VLPP, mild hypermobility

52. Physical examination of Pelvic Floor Dysfunction
General examination- cancer screen, stool OB, urinalysis, physical examination
Neurological examination- paresthesia of dermatome, bulbocavernous reflex, voluntary contraction of anal sphincter
Pelvic examination- cystocele, rectocele,uterine prolapse, vault prolapse
Urinary incontinence by Valsalva maneuver or coughing

53. Staging of Pelvic Organ Prolapse
Stage 0 - no prolapse
Stage I - the most distal portion is >1cm above level of hymen
Stage II - The most distal portion is <1cm proximal or distal to plane of hymen
Stage III - The most distal portion is >1cm below plane of hymen, but < total vaginal length - 2 cm
Stage IV - complete eversion of total length of lower genital tract, the distal portion is > TVL-2 cm, i.e. cervix or vaginal cuff

54. Evaluation of Pelvic Floor Muscle Function
Assessing patient’s ability to contract and relax pelvic muscles separately
Measuring the force of contraction
Palpation of thickness of pelvic floor musculatures
Electromyography
Pressure recording

55. Measurement of Bladder Base Descent (The Q-tip Test)

56. Lower Urinary Tract Symptoms caused by Pelvic Organ Prolapse
Stress incontinence
Frequency, urgency, urge incontinence
Hesitancy, weak stream, incomplete empty
Manual reduction of prolapse for voiding
Positional change to start or complete voiding

57. Bowel Symptoms caused by Pelvic Organ Prolapse
Difficulty with defecation
Incontinence of flatus
Incontinence of liquid stool
Incontinence of solid stool
Fecal staining of underwear
Digital manipulation to complete defecation
Feeling of incomplete evacuation
Rectal protrusion during or after defecation

58. Sexual symptoms caused by Pelvic Organ Prolapse
Vaginal coitus?
Frequency of vaginal coitus?
Painful coitus?
Satisfaction with sexual activity?
Change in orgasm?
Incontinence experienced during sexual activity?

59. Local symptoms caused by Pelvic Organ Prolapse
Vaginal pressure or heaviness
Vaginal or perineal pain
Sensation or awareness of tissue protrusion from vagina
Low back pain
Abdominal pressure or pain
Observation or palpation of a mass